Last Modified: 2/5/2010
Location: FL, PR, USVI
Business: Part A
For PPS claims, and claims with provider numbers beginning with '210', the admission date falls within a risk group health organization (GHO) paid period, but no GHO paid code or condition code '69', is indicated on the claim.
*** OR ***
For Non-PPS (prospective payment system) inpatient and skilled nursing facility (SNF) claims, the statement dates fall within, or overlap a risk GHO period, but no GHO paid code or condition code ‘69’ is indicated on the claim.
Tips
Always remember to check beneficiary eligibility prior to submitting the claims to your Medicare Administrative Contractor (MAC). There are two ways to obtain this information:
1. Direct Data Entry (DDE) users can pull the eligibility information by using the ELGA (eligibility A) or HIQA (health insurance query A) screens. Hospice information will show on page 2 for both the ELGA and HIQA screens.
2. Contact the interactive voice response (IVR) unit.
If the GHO has paid on the claim, you must submit the appropriate code and or condition code "69" on the claim.
Condition code 69 = IME/DGME/N&A Payment Only
Code indicates a request for a supplemental payment for IME/DGME/N&AH (Indirect Medical Education/Graduate Medical Education/Nursing and Allied Health)
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Source: FCSO Education Action Team
